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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440415
Report Date: 04/14/2022
Date Signed: 04/14/2022 05:19:45 PM


Document Has Been Signed on 04/14/2022 05:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:VILLA BOARD AND CARE HOMEFACILITY NUMBER:
071440415
ADMINISTRATOR:VILLA, DANIEL D.FACILITY TYPE:
740
ADDRESS:831 CORAL DR.TELEPHONE:
(510) 799-5572
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY:6CENSUS: 1DATE:
04/14/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Daniel Villa, AdministratorTIME COMPLETED:
05:20 PM
NARRATIVE
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An Informal Conference was held on 4/14/2022 at 2:00pm, via remote. The informal conference process was explained to the Administrator. The Administrator was also informed that this Informal Conference is part of the administrative action process and that further citations will result in a formal Non-Compliance Plan, and may lead to a referral to the Department's Legal Division for a possible Administrative action.

Present during the meeting were Licensing Program Manager (LPM) Jeremy Fong, LPM Harpreet Humpal, Licensing Program Analyst (LPA) Carol Fowler, LPA Laura Hall, Administrator Daniel Villa. The purpose of today's Informal Conference was to discuss the recent deficiency at the Administrators facility from a annual visit 2/17/2022.

LPM J. Fong, LPM H. Humpal, LPA C. Fowler and LPA L. Hall discussed the following issue:
-Accepting a bedridden resident with a restricted condition without an exception.
-Staff training for a resident with a restricted condition.
-Incomplete resident file.
-Providing a care plan for the resident.

During the meeting, the licensee agree to submit proof of the following by April 18, 2022:
- A formal letter requesting an exemption.
- A letter from the residents family.
-A care plan.

The following deficiency was issued for administrators qualifications (see LIC 809D) administrator failed to submit an exception request for the resident with a restricted health condition before accepting resident into the facility.
(cont 809-C)
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2022 05:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: VILLA BOARD AND CARE HOME
FACILITY NUMBER: 071440415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2022
Section Cited

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(a) All facilities shall have a qualified and currently certified administrator...freedom from other responsibilities and shall be on the premises a sufficient number of hours ... there shall be coverage... (d) The administrator shall have the ...Sections 87405(d)(1) through (7). ....
This requirement was not met as evidence by:
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Based on LPA's observation licensee did not comply with the section cited ablove which poses and immediate helath and safety risk to clients.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: VILLA BOARD AND CARE HOME
FACILITY NUMBER: 071440415
VISIT DATE: 04/14/2022
NARRATIVE
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Civil Penalty continues as the licensee has failed to submit requested documents
Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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